Provider Demographics
NPI:1063797462
Name:ROSS ROUPAS BURD & SULLIVAN DDS PLLC
Entity type:Organization
Organization Name:ROSS ROUPAS BURD & SULLIVAN DDS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER / ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANASTASI
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROUPAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:704-568-8010
Mailing Address - Street 1:5833 PHYLISS LN
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9031
Mailing Address - Country:US
Mailing Address - Phone:704-568-8010
Mailing Address - Fax:
Practice Address - Street 1:901 OAK FOREST DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5146
Practice Address - Country:US
Practice Address - Phone:704-568-8010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8215122300000X
NC55451223G0001X
NC41211223G0001X
NC6304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty